The nurse will be using the Braden Scale with each admit to the longterm care center. Which of these will be utilized in a Braden Scale assessment? (Select all that apply.)

Choice A reason: The client is in a private room is not an observation that requires further action by the nurse, because it is appropriate and desirable. The client with reduced immunity should be in a private room, as it can reduce the exposure to pathogens or allergens that may cause infection or inflammation. The client with reduced immunity has a weakened or impaired immune system, which makes them more susceptible and vulnerable to infection. The private room can also provide privacy, comfort, and security for the client.

Choice B reason: The client has a dedicated vital signs machine is not an observation that requires further action by the nurse, because it is appropriate and desirable. The client with reduced immunity should have a dedicated vital signs machine, as it can prevent the crosscontamination or transmission of pathogens or allergens that may cause infection or inflammation. The vital signs machine is a device that measures the blood pressure, pulse, temperature, and oxygen saturation of the client. The vital signs machine can be contaminated by the blood, body fluids, or secretions of the client or other clients, and can harbor bacteria, viruses, or fungi. The dedicated vital signs machine can also ensure the accuracy, consistency, and availability of the measurements for the client.

Choice C reason: The client has a vase of fresh flowers on the table is an observation that requires further action by the nurse, because it is inappropriate and undesirable. The client with reduced immunity should not have a vase of fresh flowers on the table, as it can increase the exposure to pathogens or allergens that may cause infection or inflammation. The fresh flowers are a source of mold, pollen, or insects, which can trigger allergic reactions, respiratory distress, or skin irritation. The fresh flowers can also contain bacteria, viruses, or fungi, which can infect the client through inhalation, ingestion, or contact. The vase of fresh flowers should be removed from the room and replaced with artificial flowers, pictures, or cards.

Choice D reason: There is hand sanitizer by the door is not an observation that requires further action by the nurse, because it is appropriate and desirable. The client with reduced immunity should have hand sanitizer by the door, as it can promote the hand hygiene and infection prevention of the client and others. Hand sanitizer is a product that contains alcohol or other agents that can kill or reduce the number of pathogens or allergens that may cause infection or inflammation. Hand sanitizer should be used by the client, the staff, and the visitors before and after entering or leaving the room, or after touching any objects or surfaces in the room.

Choice A reason: The client having a butterfly rash is not a concerning finding in a client with SLE. A butterfly rash is a malar rash that appears across the cheeks and the bridge of the nose. It is a common sign of SLE and may flare up or fade depending on the disease activity. It does not indicate any serious complication or organ damage.

Choice B reason: A blood pressure of 126/85 mm Hg is not a concerning finding in a client with SLE. This blood pressure is within the normal range and does not indicate hypertension or hypotension. Hypertension is a possible complication of SLE that may affect the kidneys, the heart, or the brain. Hypotension may indicate shock, dehydration, or infection.

Choice C reason: The client reporting chronic fatigue is not a concerning finding in a client with SLE. Chronic fatigue is a common symptom of SLE that affects the quality of life and the ability to perform daily activities. It may be caused by inflammation, pain, anemia, depression, or medication side effects. It does not indicate any acute or lifethreatening condition.

Choice D reason: A urine output of 20 mL/hour is a concerning finding in a client with SLE. This urine output is below the normal range of 30 to 50 mL/hour and indicates oliguria, which is a reduced urine production. Oliguria may indicate acute kidney injury, which is a serious complication of SLE that may lead to renal failure or death. The nurse should monitor the client's urine output, fluid balance, electrolytes, and kidney function and report any abnormal findings to the provider.